Professional Skills Urology Core Module Trustin Domes Outline • Brief Anatomy of Scrotum and Prostate • Physical Examination: CVA, Scrotum and DRE • Case Scenarios – LUTS – Hematuria – Upper and lower urinary tract obstruction – Scrotal Masses/Pain Anatomy of Scrotal Contents • Vessels: – Testicle has 3 arterial blood supplies: • Testicular artery • Cremasteric artery • Deferential artery – Pampiniform venous plexus • • • • Lymphatics Nerves Cremasteric muscle/fascia Vas deferens Anatomy of Scrotal Contents • Vas is the most posterior component of spermatic cord • Tunica vaginalis surrounds the anterior 2/3rd of the testicle and creates a potential space for hydroceles and hematoceles Clinical Anatomy of the Prostate Verma S , Rajesh A AJR 2011;196:S1-S10 Prostate Anatomy • Peripheral Zone = 85% of prostate cancer originate in this zone, therefore are detected on DRE • Transition Zone = site of benign prostatic hyperplasia CVA and Ballottement If CVA tenderness think: - Renal colic - Pyelonephritis - Significant renal trauma - Renal vascular occlusion If you can ballot the kidney think: - Large renal mass - Polycystic kidney disease - Severely hydronephrotic kidney Physical Examination of the Scrotum • Best to examine the man in both the supine and upright positions – Helps to demonstrate conditions that change with position: hernias and varicoceles • Bimanual examination of each testicle, adenxa and spermatic cord – Testicular size, consistency, masses, tenderness • Normal testis size 16-20 cc (2 x 4 cm) – Examine cord upright (+/- valsalva) to assess for presence of vas deferens, inguinal hernia and varicocele Cremasteric Reflex • Reflex elicited by stroking the medial thigh causes an ipsilateral contraction of the cremasteric muscle (bringing the testicle closer to the external inguinal ring) • Reflex tests L1-L2 (genitofemoral nerve responsible for afferent and efferent limbs) • Typically absent in testicular torsion – Negative predictive value of over 90% Transillumination • Important to help differentiate solid from fluid-filled masses • Hydroceles and spermatoceles will transilluminate, other scrotal masses typically WILL NOT Hydrocele Varicoceles • Dilated veins of the paminiform plexus • Predominant left-sided (98%) • Isolated right-sided varicocele may be caused by a retroperitoneal – NEED abdominal imaging • Varicocele grading: – Grade I: palpable only with valsalva – Grade II: easily palpable without valsalva Grade III: “bag of worms” – Grade III: large, visible through scrotal skin Digital Rectal Examination Comment on: • Prostate • Size • Symmetry • Consistency • Tenderness • Nodules • Rectal/Anal Masses • Rectal Tone Prostate size Average prostate size is approximately 25 cc in men older than 50 years 25 cc 150 cc How many finger-breadths across? Can you get to the top (base)?